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<form enctype="multipart/form-data" method="post" action="http://www.response-o-matic.com/mail.php" accept-charset="UTF-8">
<div>
<input type="hidden" name="acctid" id="acctid" value="6kc4c09rfnysjg4q" />
<input type="hidden" name="formid" id="formid" value="843923" />
<input type="hidden" name="required_vars" id="required_vars" value="field-7c96b896cb6d55e,email,field-7c311bca6a52aac,field-9ee91828f66c763,field-bf506ddc802cad9,field-6ec3ab698491801,field-95e322989e17542" />
</div>
<table cellspacing="5" cellpadding="5" border="0">
<tr>
<td valign="top">
<strong>Name 名字 :</strong>
</td>
<td valign="top">
<input type="text" name="field-7c96b896cb6d55e" id="field-7c96b896cb6d55e" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Email Address 电子邮件 :</strong>
</td>
<td valign="top">
<input type="text" name="email" id="email" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Contact Number 联络号码 :</strong>
</td>
<td valign="top">
<input type="text" name="field-e25b712b856f957" id="field-e25b712b856f957" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Delivery Address 地址 : </strong>
</td>
<td valign="top">
<textarea name="field-3c4d4f252be1f31" id="field-3c4d4f252be1f31" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Item Code/Colour/Quantity/Size :</strong>
</td>
<td valign="top">
<textarea name="field-7c311bca6a52aac" id="field-7c311bca6a52aac" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Delivery Option运输选项 :</strong>
</td>
<td valign="top">
<input type="radio" name="field-9ee91828f66c763" id="field-9ee91828f66c763_0" value="Skynet West Malaysia" /> Skynet West Malaysia<br/>
<input type="radio" name="field-9ee91828f66c763" id="field-9ee91828f66c763_1" value="Skynet East Malaysia" /> Skynet East Malaysia<br/>
<input type="radio" name="field-9ee91828f66c763" id="field-9ee91828f66c763_2" value="Other (Write on Remark box)" /> Other (Write on Remark box)<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Payment Option 付款选项 :</strong>
</td>
<td valign="top">
<input type="radio" name="field-bf506ddc802cad9" id="field-bf506ddc802cad9_0" value="Maybank [S.I.Global(M)Sdn Bhd 5144 0400 4908]" /> Maybank [S.I.Global(M)Sdn Bhd 5144 0400 4908]<br/>
<input type="radio" name="field-bf506ddc802cad9" id="field-bf506ddc802cad9_1" value="PayPal [sig.3d@hotmail.com]" /> PayPal [sig.3d@hotmail.com]<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Total Amount 总金额 :</strong>
</td>
<td valign="top">
<input type="text" name="field-6ec3ab698491801" id="field-6ec3ab698491801" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Remark 备注 :</strong>
</td>
<td valign="top">
<textarea name="field-95e322989e17542" id="field-95e322989e17542" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
</form>
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